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Public sector monopolies are a good thing right. They can’t affect private provision or innovation, and they are what they are. And in the case of the National Health Service in the UK, it’s a miracle. Thank goodness laws protect us from private companies taking over the NHS.

That’s the public service dialectic. Well, I have some worrying news for you.

Baxter’s law (also known as the Bell doctrine) is a law of economics that describes how a monopoly in a regulated industry can extend into, and dominate a non-regulated industry, named after law professor William Francis Baxter who was an antitrust law professor at Stanford University.

Here’s an example:

A new nurse-led social enterprise sets up on the South Coast of England to provide a wound dressing service. The local CCG likes the new service and signs a three-year contract. Costs go down as the service dresses wounds more innovatively, patients spend less time as an inpatient and pharmacy bills reduce.

At the end of the Contract, the CCG advertises a new Contract. The local NHS provider offers a lower price for the next tranche of the agreement. They undercut the local social enterprise by using funding and revenue from other areas of the local health monopoly. They win the new contract. Of course, they do this to protect their income in others areas of their business. Classic monopolistic and anti-competitive behaviour.

So what happened?

Did the cost of care on the South Coast go down? Did the quality go up? Or perhaps the NHS used it’s monopoly to reach into a Third Sector and kill innovation and alternative provision and protect its income. I would content that Baxter’s law applied and the NHS used its power to stifle innovation.

My concern is that many are unaware of the anti-competitive nature of this monopoly position. Next time you attend a meeting looking at NHS Contracts or as a member of the public at a Health and Wellbeing Board you might think to ask;

What steps are we/you talking to limit the monopoly of NHS provision?

Are we/you aware of any examples of the NHS limiting innovation or new service provision through the use of economic muscle?

You may have been following the changes to the NHS over the last few years. Or perhaps you are just a user of services, going to your General Practitioner and then to a local hospital. Either way, you should know that your local Council has been given some wide-ranging powers to provide local health and social care services. Who cares? It’s a reasonable response to all of the changes. But there are some things should concern you.

in the light of these issues I want to look at what Local Health and Wellbeing Boards are discussing in their meetings.

Using a search engine of your choice, you will quickly find the papers of you local HWB on the internet. And that’s where it pretty much turns to rat shit. The jargon and impenetrable language are there in the first paragraph. Here is the explanation of what the HWB does in Brighton.

The purpose of the Board is to provide system leadership to the health and local authority functions relating to health & wellbeing in Brighton & Hove. It promotes the health and wellbeing of the people in its area through the development of improved and integrated health and social care services.

The HWB is responsible for the co-ordinated delivery of services across adult social care, public health, and health and wellbeing of children and young peoples’ services. This includes decision making in relation to those services within Adult Services, Children’s Services, Public Health and decisions relating to the joint commissioning of children’s and adult social care and health services (s75 agreements).

Are you any the wiser? Perhaps the focus on young people caught your eye. Although you may now be worrying about the three data points I highlighted.

Reading the Agenda and the Minutes of the meetings won’t help you. They’re even more Delphic.

The most concerning element for any Public body are the meetings they held in camera. They regularly exclude the public from their discussions.

Members are often keen to show they have no conflict of interests, and it’s usually the first agenda item. But no one seems concerned that as mainly elected officials they are in conflict with their electorate for excluding them. You might also reasonably ask why there are so many doctors and so few nurses as members of your HWB. Perhaps too much interest all round.

So, if you have the time to attend an HWB meeting, go and listen to their arcane discussions, see if you understand what they are doing in your name.

Promoting individual well-being. It’s not good enough to just hand out leaflets, it requires a proper campaign to address the well-being in all demographics. Cherry picking vulnerable and disabled people for example would discriminate against those that are trying to keep themselves fit and well. It’s as important to engage the self funding middle class as pensioners receiving pension credits. And it’s important to see their children as an constituency of interested people.

Preventing needs for care and support. Prevention has to be done at scale, there is no point in having two people as the single point of contact in a Council. This approach will fail for even the most vulnerable groups. Typically there are 15-20,000 chronically lonely people in a London Borough. To address a problem of this scale, the solution has to the facilitation of self and community help. Councils cannot set themselves up as the one place to go for everything. They need to develop the social capital within their communities to tackle this problem within each Ward. In Ealing the Councils approach touches less then 1,000 of the 17,000 chronically lonely people in the Borough.

Promoting integration of care and support with health services etc. The NHS cannot have it both ways, complaining about a shortage of funding and failing to engage with the social capital development in their communities. The NHS has over the last few years conducted a scorched earth policy around their services. Placing impossible contract requirements on Social Enterprises, often letting contracts to itself and failing to integrate its care services in a meaningful way with local community organisations. As as a result, there is little innovation in local health and care services.

Providing information and advice. If you have looked at any council health and care information services, this link is for older people in Ealing, (you can make your own mind up how useful it is), most information is partial, out of date, broadly inaccurate and not designed with the user in mind. Information is not even curated for particular demographic groups. More often than not they are just a list of organisations and locations that mean nothing to local people. Contact number is really answered and access and disability services poorly described. So why do authorities see this as a useful way to spend resources, at best it’s likely to be a box ticking exercise to address the bare minimum of requirements.

Promoting diversity and quality in the provision of services. The first step here is to allow online feedback on the services, few councils do this, and it’s very hard to understand the quality of a service. In Ealing you can complain but we have no idea what people have been complaining about, no one can judge the quality of the a service. Pretty much all industries have worked out the benefits of listening to their customers.

Co-operating generally. Looking beyond local services and embracing the people that create and run them is a better way of thinking about how cooperation might work. Most Councils have no idea of who runs such 3rd services and does not provide any support services for them. The relationship is often transactional and based on erratic funding. Most of the effort of these hugely generous people is unacknowledged and certainly never engaged with. More often then not the Council is quick to criticise even the slightest failing in such people, and yet it ignores the rising complaint about its lack of local relevant services, blaming anyone but criticise itself for the issues.

Addresses these issues would not cost a great deal, probably no more than is being spent currently. Sadly not doing it means that peoples self-reliance is under-minded and they struggle to stay away from the local health and care services. We should all demand higher standards of the information provision and local coordination within communities this would go a long way to reducing costs and improving outcomes.

In the fifth blog, I look at the role health and social care services played in the last nine months of my Mum’s life. I have already discussed the role of decision making and what to expect. So I will try not to repeat that here.

The support we received from the NHS was pretty good, a couple of times my Mum was discharged from hospital without medication, this caused a great deal of work for our GP. I would say the NHS did what it could, I would not say that my Mum’s care was world class, staff tried their best but they seemed distracted and unsupported most of the time. The NHS is clearly under pressure, but I did not get the feeling that more money would solve its problems. It was mainly poor process and lack of communication that caused most of the issues. Sadly I don’t think the Royal Surrey County Hospital in Guildford is a good hospital.

Such a short time

The NHS and Social Services are under so much pressure don’t expect to have much engagement unless it’s in their interests to do so. I seemed to me that everything they do is part of some fine financial judgement. At best I could expect health professionals to visit Mum less than 1 hour per week in any programmatic way. Yes, the GP came to the house, if requested, but community nurses will only come out if the NHS saw it as a way of stopping the use of a more expensive form of provision. In my Mum’s case, she realised that calling 999 was the only way of guaranteeing health service support. As a result, the local community team put a regular visit in place to help my Mother stay at home and not call 999. Surrey Social Services never visited my Mother.

This Community support was vital because it enabled me to have regular contact with my Mother’s care team and of course it gave my Mum the confidence she needed.

Filling out the endless Forms

You will find that you will need to fill out numerous forms, Blue Badge forms, support and attendance payments, access to services and complaints and feedback. All of them are long, complex and ambiguous. I would say that most of them are designed to make it impossible to complete them without specialist help. The worst of them is the National Reporting and Learning System (NRLS). Multiple pages of detail that you need to complete if you think you have witnessed unsafe care in an NHS establishment. (Note the name is pretty obscure, it’s probably meant to be.)

My top tip with Forms is to get the health and social care professionals to fill them out for you. And the only way to do that is the next top tip. If the Hospital wants you to do something, ask them to do something for you. So when it became apparent that my mum needed support at home, I asked social services and the discharge team in the hospital to complete the Attendance Allowance form for my Mum. Guess what, they did, and it was approved, and I took Mum home. The whole thing took less than 2 hours. We had spent some months trying to apply ourselves for the allowance with no success.

No sharing of information

I have mentioned in a previous blog the lack of sharing of information. Health and Social Care don’t share any significant information. So you will have to act as the coordination hub. Your phone camera is a great way of recording forms and general information.

The NHS doesn’t do email with patients and family

I found if hard to communicate with healthcare professionals, they don’t want to use Email as a channel. The best I could do was SMS, and even then some would not accept attachments such as photos of meds and reports. It seemed like a policy decision because everyone appears to have the same response.

It struck me that the Community team just needed a Customer/Patient Relationship Management system to stay efficiently connected to their workload.

My Top Tips

Get help from healthcare professionals to fill out forms

Collect the mobile phone numbers of people who are involved in care; you can then SMS them.

Make it clear when it’s in the interests of the NHS to do or try something different. You may be able to change their support response and improve outcomes for everyone.

In my fourth blog, I look at finding support for my Mother in the last few years of her life.

Well, this may be the most surprising thing that I learnt. Finding help and support is hard. I don’t mean health or social care; we will come to that in my next blog. I mean all the stuff that made my Mums life more fulfilled, more connected and happier. Despite all of the years of the internet, no one has cracked this one. Maybe the reason older people don’t use the internet is that there is little for them to use.

I began to look for three types of services close to my Mother’s home:

Personal – finding a hairdresser that would come to Mum, someone to do her nails and perhaps bring some clothes for her to try. A dentist that does not have steps into the surgery.

Household – cleaning services, a handyman, painters and general helpers.

Community – lunch clubs, trips out and art and social events for older people.

There’s no database of this stuff, well not one that worked for me for services local to my Mother lived. The local council would not make recommendations; the GP knew nothing, notice boards were generally out of date. No one seemed to know anything. Try it for yourself, see if you can find services for someone in your area. The authorities are quick to complain about older people falling into statutory care, but they seem to no idea how to provide an alternative solution.

I realised that I was going to have to make a plan and there are my top tips:

When I went to see Mum, I would always look around for services. I had an Evernote notebook on my Phone and recorded any useful information

I used my camera to take photos of noticeboards so I could look for any relevant services.

Don’t expect to find any sensible databases of service you are going to have to create your own

If you have the opportunity to ask someone about services, always ask, everyone now and then you will find someone that knows who provides services.

Use the web to find what you can, sometimes some areas have good resources, in my Mum’s case there was no such resource, but I used the good ones as a key to the things I might be able to find.

Find out where older people go for coffee, sometimes the café owner has an excellent idea of what is going on locally.

Local charities and their shops are sometimes a good source of information. But don’t expect much.

There should be a thought at the heart of every organisation; are we doing good or ill? In Microsoft we worried about a new found monopoly and we engaged with this through responsible leadership. We understood that our role as managers had to change, we had a responsibility to our partners and customers beyond just making money for our shareholders. And over a number of years we became a better group of leaders.

In the NHS I am not sure we have yet to fully understand the constraints and opportunities afforded to us by our health and social care monopoly in England. Monopolies nearly always display a number of traits:

A lack of transparency

Poor levels of service.

No or low consumer power.

high prices for low quality goods and services.

out dated goods and services with little or no innovation.

I believe that these ought to be leadership concerns of NHS England.

Despite rises in medical legal costs through greater insurance payouts and premiums, the Francis Report and the Institute of Customer Service Report 2014,that shows lower and lower levels of customer satisfaction within the NHS, the NHS has yet to focus managers in the same way as those of the commercial sector near monopolies.

It may that the NHS has never really developed, in organisational terms, beyond the passive aggressive org that Neilson so graphically describes in his Harvard Business Review article.

It’s time we all demanded more of NHS leadership, the call for privatisation is the wrong way of tackling the issues of lack of competition. NHS Leaders should address the monopoly traits. This could be achieved through greater transparency, and by commissioning services for improvements in public, patient and professional experience.

There is some light at the end of the tunnel, the Kings Fund paper Reforming the NHS… is a very good place to start. But until the traits are on the agenda of every NHS leader we are not going to make progress.

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About John Coulthard

If you’re sure about something, you can guarantee that someone else not very far away will be sure about the opposite. Our views and opinions are a product of our cultural conditioning. Sometimes the effect of failing to take a broader perspective is benign, but more often in doing so, you exclude, underestimate or marginalise whole segments of society. I aim to try to see the gaps in provision, challenge the assumptions and perhaps provide a broad angle view of my small part of the world.